XLPharmacy - More on Medicare Doughnut Hole

What Is This Infamous Doughnut Hole In Medicare I Hear About?


The hole is a gap in coverage that Congress built into Medicare's first-ever prescription plan. The gap requires most people with drug expenses over $2,250 to pay 100 percent out of pocket before coverage resumes when they reach the $5,100 level.

Millions of beneficiaries like this one are going to have to find a way to get past Medicare's infamous doughnut hole. It is estimated that about 3.4 million beneficiaries, or about 8 percent of those enrolled in the plan, will fall into the gap this year.

Under the standard Medicare benefit, people generally have to pay a $250 deductible and 25 percent of drug costs up to $2,250. When costs paid by both the plan and the beneficiary reach that $2,250 figure, the beneficiary will have to pay all drug expenses until their total out-of-pocket expense reaches $5,100 -- generally a $2,850 gap. After that, they will be covered again for all but 5 percent of drug costs.

Does This Doughnut Hole Affect Everyone?

No.

More than a third of Medicare recipients get their prescription coverage through an employer or other program and are not subject to coverage gaps. Some recipients chose higher-cost drug benefit plans that provide some coverage through the gap. Others don't purchase enough drugs to reach the spending limit. Also shielded from the doughnut hole are low-income people who qualify for Medicare subsidies. As well as those who receive their prescriptions through both Medicare and Medicaid.

Medicare's prescription drug coverage gap has been well publicized. Still, many seniors are unaware of it, don't fully understand it or hit it sooner than they expected. Others don’t realize it until they begin receiving warnings from their plans that they are nearing their spending limits. While still others are discovering a doughnut hole only when they visit the pharmacy and find their $25 prescription drug co-payments replaced by bills for hundreds of dollars. Talk about a rude awakening.

Once most people reach the doughnut hole they won’t be able to get out of it, because if people hit the gap more than halfway through the year, they are unlikely to reach the spending threshold before their policy finishes at the end of the year. The idea of having to continue paying premiums for almost no coverage irritates a lot of seniors.

What Choices Are There If This Happens To Me?

• Some beneficiaries are glad to have the insurance in case their drug needs increase. So bite the bullet and continue by pay for prescriptions full price until the next year kicks in.
• Pay for the prescriptions while in the doughnut hole with whatever you have saved if you know you’ll pass the doughnut hole and receive help again before the end of the year.
• Some health advocates suggest that beneficiaries carefully weigh whether the costs of getting out of the hole are worth it. For example, if a beneficiary determines he or she will never reach the spending threshold before the end of the year, it might make more sense to buy drugs strictly based on cost rather than stay with their plan's network of drug providers.
• If you calculate and realize they you will never reach the catastrophic level, you can go anywhere you want to get your medications.
• Consider drug discount card programs offered by a variety of companies, including drug stores. For a specific medication, beneficiaries can contact the manufacturer to see if they qualify for a company's patient assistance program, which generally will have income eligibility requirements.
• Some people could save money by splitting pills. This involves buying higher doses of a medication and cutting tablets in half. But patients should seek their physician's advice before doing so.
• Beneficiaries who have already fallen into the hole might want to consider purchasing a more comprehensive policy for 2007, Gray said. Several companies offer policies with higher monthly premiums than standard plans. But they offer partial or complete coverage through the gap.
• Even more beneficiaries could fall into the hole next year. In this first year of the program, people were allowed to sign up as late as May. Next year's beneficiaries will have a full year of coverage and might hit the hole earlier.

Some Tips To Consider:

• Find out if you can switch to lower-cost or generic drugs.
  See if you qualify for assistance through a government program or pharmaceutical company.
• Shop for the best drug prices. If you plan to apply purchases toward the doughnut hole, make sure the pharmacy is in your plan's network.
  Evaluate coverage options for next year. Consider total costs, not just monthly premiums.
• One Senior stated he would go back to a respected and licensed Canadian Pharmacy and purchase their medications from there like they had been doing before starting the new Medicare plan to begin with.

Information on the side of Canadian Pharmacies and US Insurers: Insurers contract with specific pharmacies. They will count only those purchases made in their network in calculating when a beneficiary has reached the hole. Additionally, drugs purchased through Canadian or other international pharmacies don't count. You will have to consider the in-pocket savings when considering Canadian Pharmacies. If you know you will not be climbing out of the “doughnut hole” before the end of the year, this may be a viable and more affordable solution, as Canadian Pharmacies have a cap on their medication costs and purchase their medications from the same International pharmaceutical manufactures as the U.S. such as Novartis, Cipla Abbot, Aventis, Bayer, Dr. Reddy's, Merck, Lilly, GlaxoSmithKline and Ganbaxy

Informational Resources:

XLPharmacy Canada
MSN Health Blogs
WordPress Health Blogs I
WordPress Health Blogs II